Coos Bay Children’s Academy Pesticide Exposure Incident .
Coos Bay Children’s AcademyPesticide Exposure IncidentInvestigation ReportPesticide Exposure Safety & TrackingPublic Health DivisionOregon Health AuthorityOctober 2017
Table of ContentsEXECUTIVE SUMMARY . 1Introduction . 1Results . 1Agencies’ response . 1BACKGROUND . 2The pesticide exposure incident . 2Exposure Timeline . 2Oregon Health Authority’s Investigation . 2Pesticides & Health . 3Pesticide Applications . 3METHODS . 3Collaboration. 3Outreach . 4Data Collection . 4Acute Pesticide Poisoning Classifications . 4Data Analysis . 5RESULTS . 6Respondents . 6Health Outcomes . 6Acute Pesticide Poisoning Classification . 6Epidemic Curve . 7Alternative Causes . 8DISCUSSION. 8Acute Pesticide Poisoning Cases . 8Epidemic Curve . 9Alternative Causes . 9Limitations . 9CONCLUSION. 10RESOURCES . 11CONTACT US . 12REFERENCES . 13i
APPENDIX . 15APPENDIX A. SCREENING SURVEY. 15APPENDIX B. QUESTIONNAIRE CALLING SOP. 17APPENDIX C. QUESTIONNAIRE . 19APPENDIX D. NIOSH ACUTE PESTICIDE POISONING CERTAINTY CLASSIFICATION . 24Clinical Description. 24Classification Criteria . 25A. Documentation of Pesticide Exposure. 25B. Documentation of Adverse Health Effect . 26C. Evidence Supporting a Causal Relationship Between Pesticide Exposure and Health Effects . 26APPENDIX E. NIOSH ACUTE PESTICIDE POISONING SEVERITY CLASSIFICATION . 28Purpose: . 28Rationale: . 28Description: . 28S-1 Death . 29S-2 High severity illness or injury . 29S-3 Moderate severity illness or injury . 29S-4 Low severity illness or injury . 29APPENDIX F. ACUTE PESTICIDE POISONING CLASSIFICATION FORM . 30ii
EXECUTIVE SUMMARYIntroductionOn May 12, 2017, the Coos Bay Children’s Academy day care closed after children and employeesreported symptoms following a pesticide application during the week of May 1. Concerned employeesand parents notified the Coos (County) Health & Wellness Public Health Division during that week. CoosCounty informed the Oregon Department of Education’s Office of Childcare and sought advice from theNational Pesticide Information Center. The Pesticide Analytical and Response Center, which coordinatesstate agency review of pesticide incidents, learned about the incident through an article published inThe Oregonian and mobilized all relevant agencies. Oregon Health Authority, Oregon Department ofAgriculture and Oregon Occupational Safety and Health Administration each initiated investigations.The focus of Oregon Health Authority’s investigation was to determine whether a causal associationexisted between the pesticide applications and the reported symptoms.ResultsCoos Bay Children’s Academy had 24 employees and an estimated 117 daycare attendees. OregonHealth Authority staff surveyed 49 individuals who reported symptoms and reviewed 17 medicalrecords. Coughing was the most common symptom reported, followed by eye irritation and runny nose.Based on the questionnaire responses and medical record review Oregon Health Authority classified 30of the children and adults as cases of acute pesticide poisoning (21% of the children and employees whovisited Coos Bay Children’s Academy during the week following the initial pesticide application). Thecases are of “low” severity since symptoms were mild and resolved on their own after a short time.Sixty percent of individuals classified with acute pesticide poisoning started experiencing their firstsymptom on Monday, May 1 (shortly after the first pesticide application on Saturday, April 29) followedby Tuesday and Wednesday in a clear decay pattern. There were no spikes in symptoms or cases onThursday, May 4, after a second pesticide application. Thus, it is likely that the first pesticide applicationwas largely responsible for the reported symptoms.Agencies’ responseOregon Department of Agriculture issued civil penalties and violations to Coos Bay Children’s Academy,the owner of the facility and the pesticide applicator for performing pesticide applications in a faulty,careless or negligent manner.Oregon Occupational Safety and Health Administration issued civil penalties and violations to Coos BayChildren’s Academy for failure to comply with hazard communication rules requiring employers to traintheir employees to recognize chemical hazards and to take the necessary precautions to protectthemselves, and failure to establish and maintain a safety committee for employees.Pesticide Analytic and Response Center developed a plan to outreach to all Oregon state agencies,informing them how to report pesticide-related incidents and concerns to the Center.Oregon Health Authority is updating guidelines for investigating pesticide poisoning incidents andworking to remind local health authorities of requirements to report pesticide poisoning incidents.1
BACKGROUNDThe pesticide exposure incidentOn May 12, 2017, the Coos Bay Children’s Academy (CBCA) day care closed after children andemployees reported symptoms following a possible pesticide exposure during the week of May 1, 2017.Coos Bay Children’s Academy had 24 employees and an estimated 117 daycare attendees. Concernedemployees and parents notified the Coos (County) Health & Wellness Public Health Division during thatweek; Coos County informed the Oregon Department of Education’s Office of Childcare and soughtadvice from the National Pesticide Information Center located at Oregon State University. Concernedemployees and parents also notified The Oregonian, which published an article on May 16, 2017 aboutthe incident. Soon afterwards, the Pesticide Analytical and Response Center, which coordinates stateagency review of pesticide incidents, mobilized all relevant agencies (Oregon Health Authority, OregonDepartment of Agriculture and Oregon Occupational Safety and Health Administration), each initiatingtheir own investigation. The US Environmental Protection Agency and US Occupational Safety andHealth Administration were notified.Exposure TimelineThe following timeline summarizes the pesticide exposure period at Coos Bay Children’s Academy:1. The owner purchased Tempo SC Ultra (active ingredient beta-cyfluthrin of the pyrethroid classof insecticides) and applied it at the facility on the morning of Saturday, April 29, 2017 to treatfor fleas (application 1).2. Children returned to the day care the following Monday morning (5/1/17). Some children beganexperiencing upper respiratory and eye symptoms; the flea problem persisted.3. The facility hired Western Exterminators, a professional pesticide applicator, to treat the facilityWednesday evening (5/3/17, application 2).4. Parents learned about the pesticide applications during the week of May 1. Some were concernedthat symptoms their children were experiencing could be the result of pesticide exposure.5. Carpet cleaners came to the facility Friday evening (5/5/17) to remove any pesticide residue onthe carpets. Staff reported they cleaned walls and toys.6. The Coos Bay Children’s Academy permanently closed on the following Friday, May 12.Oregon Health Authority’s InvestigationAll suspected or confirmed cases of pesticide poisoning are reportable to Oregon Health Authority, andOregon Health Authority may investigate these, as outlined in Oregon Administrative Rules (OAR) 333018, 333-019 (Investigation and control of Diseases, 2017).The Pesticide Exposure Safety and Tracking program at Oregon Health Authority investigates cases ofpesticide poisoning resulting from acute exposures, termed acute pesticide poisonings, after allimmediate threats to safety and health have been addressed. The Pesticide Exposure Safety andTracking program focuses on acute pesticide exposure since the effects of chronic exposures can bedifficult to confirm. These investigations use protocols developed by the National Institute ofOccupational Safety and Health’s (NIOSH) Sentinel Event Notification System for Occupational Risk(SENSOR) program to focus on population-based pesticide illness and injury surveillance (NIOSH, 2017).These investigations aim to determine whether a causal association exists between an exposure andreported symptoms. The investigations take pesticide toxicity, symptom type and duration and2
resolution, route of exposure, length of exposure, proximity to the application site, and other factorsinto consideration.Pesticides & HealthAdverse health effects from a pesticide exposure vary, depending on the pesticide’s chemicalcomposition and several exposure factors, including route and duration.Pesticides can affect both children and adults, although children may be more susceptible because oftheir smaller size, which results in a larger dose from a given exposure, and their different behaviorpatterns, which might increase their likelihood of exposure. Moreover, children's internal organs are stilldeveloping and their enzymatic, metabolic, and immune systems may provide less natural protectionthan those of an adult (EPA, 2002).Pesticide ApplicationsTempo SC Ultra Premise Spray (EPA Reg. No. 11556-124) was the first pesticide used at Coos BayChildren’s Academy to treat for fleas. Coos Bay Children’s Academy applied the pesticides around thebaseboards and carpet on Saturday, April 29. This pesticide is designed to control a broad spectrum ofinsect pests in and around animal housing, warehouses and processing and packing plants (EPA, 2017).ODA’s investigation closely focused on pesticide use according to the label. Tempo SC Ultra PremiseSpray has a “caution” signal word, the lowest level of toxicity that the EPA can assign any registeredpesticide. Its active ingredient is Beta-cyfluthrin (11.8% before dilution), a low-toxicity pyrethroid.After Tempo SC Ultra Premise Spray proved to be ineffective at eliminating fleas, Coos Bay Children’sAcademy contracted completion of a second pesticide application on the evening of Wednesday, May 3.This application, applied by a professional, focused on the interior baseboards and exterior perimeter. Itcontained three different pesticides: NyGuard IGR Concentrate (EPA Reg. No. 1021-1603), OnslaughtFast Cap Insecticide (EPA Reg. No. 1021-2574) and Suspend Polyzone (EPA Reg. No. 432-1514). Thesepesticides are designed to control a broad spectrum of insect pests, including fleas, in indoor andoutdoor areas (EPA, 2017). All three have a “caution” signal word. Their active ingredients werepyriproxyfen (10.0%), esfenvalerate (6.4%), pralethrin (9.6%) and deltamethrin (4.75%). All but thepyriproxyfen are low-toxicity pyrethroids.Adverse health effects associated with acute pyrethroid exposures can include moderate eye and skinirritation, headaches, dizziness, coughing, and difficulty breathing (EPA, 2013). There is no evidence thatpyrethroids cause birth defects or affect the reproductive systems in humans (ATSDR, 2003). Someanimal studies have suggested that, when consumed in very large amounts over a lifetime, pyrethroidsmay cause cancer (ATSDR, 2003).In addition to the adverse health effects associated with pyrethroid exposures, pyriproxyfen exposure isassociated with diarrhea (Toxnet, 2016). There is no evidence that pyriproxyfen is carcinogenic tohumans (EPA, 2016).METHODSCollaborationPesticide Exposure Safety and Tracking collaborated with toxicologists and Acute and CommunicableDisease Prevention epidemiologists within Oregon Health Authority as well as Pesticide Analytical and3
Response Center member agencies (Oregon Occupational Safety and Health - OR-OSHA, and OregonDepartment of Agriculture - ODA) to investigate the Coos Bay Children’s Academy pesticide exposureincident. All Pesticide Analytical and Response Center member agencies completed their owninvestigations.OutreachOregon Health Authority requested incident and contact information for Coos Bay Children’s Academyemployees and enrolled students from the Coos County Health Department (Coos Health & Wellness)and Oregon Department of Education Early Learning Division, Office of Child Care. Thirty-six employees(24 recent and 12 others) and 117 enrolled children were identified. Contact information includedemployees, child and parent names; phone numbers, email addresses; and mailing addresses.Data CollectionOregon Health Authority developed a seven-question online screening survey using Survey Monkey toidentify the children and employees that had reported symptoms potentially consistent with pesticideexposure after attending Coos Bay Children’s Academy the week of May 1, 2017 (Appendix A). On May25, 2017, Oregon Health Authority staff sent out an email to every parent for whom an email addresswas available, stating the purpose of our investigation and requesting that the parent follow a link tocomplete the screening survey. Staff sent two reminder emails during the following week.Oregon Health Authority staff contacted all parents who responded that their child/children hadexperienced any of these symptoms after attending Coos Bay Children’s Academy during the week ofMay 1, 2017. Oregon Health Authority staff asked these parents to complete a more in-depth phonequestionnaire (APPENDIX B). The investigative team, comprised of Pesticide Exposure Safety andTracking and Acute and Communicable Disease Prevention staff, developed questionnaires to collectpesticide exposure and health outcome information for each individual (APPENDIX C). There were 41questions related to demographics, exposure periods, health outcomes and other relevant information.This included a list of eighteen symptoms commonly associated with the active ingredients found in thepesticides that were applied (Toxnet, 2008; Toxnet, 2009; Toxnet, 2012; Toxnet, 2016). Staff followedcalling protocols and left two callback voice messages if parents did not answer.The investigative team directly contacted all employees by phone and asked them to complete aquestionnaire, since the employee list was much shorter than the enrolled student list. The investigativeteam left two voice messages on individuals’ phone requesting a call back if we were unable to reachthem. Oregon Health Authority sent an additional reminder text message to parents and employeeswho had not responded to our calls on May 31.Oregon Health Authority requested the pesticide-related medical records of all the individuals whoreported seeking medical attention after attending Coos Bay Children’s Academy the week of May 1.Acute Pesticide Poisoning ClassificationsOregon Health Authority followed National Institute for Occupational Safety and Health protocols toclassify cases of acute pesticide poisoning using completed phone questionnaires and available medicalrecords (NIOSH, 2017). The acute pesticide poisoning case definition requires: 1) a reported exposure,and 2) post-exposure symptoms (1 dermal or 1 ocular or 2 systemic symptoms) that are consistent withthe current literature. Symptoms that began before the exposure were considered attributable4
symptoms if they worsened after the exposure. Oregon Health Authority gave each case a “certainty”and a “severity” index to reflect the level of confidence that pesticide exposure actually caused thesymptom and the degree of the signs and symptoms. The acute pesticide poisoning “certainty” indexhas eight classifications that range from “definite” to “unrelated” (APPENDIX D). This protocol classifiesindividuals with “definite”, “probable”, “possible”, or “suspicious” certainty indexes as acute pesticidepoisoning cases.The acute pesticide poisoning “severity” index has four classifications: death, high severity illness orinjury, moderate severity illness or injury, and low severity illness or injury (Appendix E).Pesticide Exposure Safety and Tracking staff reviewed all case classifications containing medical recordswith a medical epidemiologist and two toxicologists at Oregon Health Authority. A toxicologist auditedten percent of all cases without medical records. This case review team reached full agreement on allthe reviewed cases before assigning a final certainty and severity index to each case (APPENDIX F).Data AnalysisOregon Health Authority entered all of the questionnaire and acute pesticide poisoning classificationdata into an Excel file and performed our analyses using The R Project for Statistical Computing software(version 3.4.0).In this report, a “child” is any student enrolled at Coos Bay Children’s Academy. An “adult” is anyemployee or parent. An “Individual” is anybody who we completed a questionnaire for and included inour analyses, unless otherwise specified.Oregon Health Authority considered the overall “exposure period” to be from Monday, May 1 throughFriday, May 5, including the first pesticide application on Saturday, April 29 through carpet cleaning onFriday, May 5. The exposure period specific to the second, professional application that occurred on theevening of Wednesday, May 3 was from Thursday through Friday of that week.Oregon Health Authority excluded symptoms that preceded exposure and did not worsen after itoccurred, and those that began more than 48 hours past a last exposure.Only medical visits related to Coos Bay Children’s Academy after an exposure (May 1 – May 5) wereincluded in the analyses.Oregon Health Authority made several assumptions during data analysis. First, Oregon Health Authorityestimated an individual’s total exposure time by including any day an individual spent time in the facilityas a whole day. Oregon Health Authority made this assumption because it was difficult to determine anindividual’s exact location and time within the facility. Second, only the symptoms clearly identified byindividuals were included in the analyses. A symptom was not included if individuals were unsure ofwhether they or their child had experienced it. Finally, Oregon Health Authority used National Institutefor Occupational Safety and Health protocols to identify cases of acute pesticide poisoning. While manyindividuals reported post-exposure symptoms, Oregon Health Authority only considered those that metthe criteria of cases of acute pesticide poisoning. The acute pesticide poisoning case count may thusunderestimate some pesticide-related symptoms.5
RESULTSRespondentsAn estimated 117 children attended Coos Bay Children’s Academy during the week of May 1. Coos BayChildren’s Academy employed twenty-four employees during the week of May 1, though it is unclearhow many total adults (employees plus parents) visited Coos Bay Children’s Academy during that period.The investigative team completed 49 (49/142 35%) questionnaires. Each survey took 15 – 45 minutesto complete. The median (minimum, maximum) age of individuals was 4 (1, 65) years. Twenty-four ofthe individuals (49%) were male. The median (minimum, maximum) days of pesticide exposure forindividuals was 4 (1, 5) days.Health OutcomesIndividuals reported post-exposure symptoms with the following categories: respiratory problems(47%), eye problems (35%), dizziness, headache, nausea or fever (24%), and skin problems (16%). 96% ofindividuals reported at least one symptom (Table 1). Fourteen individuals sought medical attention.SymptomSkin problems (irritation, burning, pain or rash)TotalN 49(Count, %)8 (16%)Dizziness, headache, nausea or fever12 (24%)Eye problems (irritation, burning, tearing,discharge, blurring or double vision)17 (35%)Respiratory problems (cough, sore throat,runny nose, sneezing, wheezing, difficultybreathing, burning nose or throat)23 (47%)Any symptom47 (96%)Table 1. Symptom Profile (Table of all reported symptoms after attending Coos Bay Children’s Academythat may have been related to the pesticide applications between Monday, May 1 and Sunday, May 7.Total percentages do not add up to 100% because individuals often reported multiple symptoms).Acute Pesticide Poisoning ClassificationOregon Health Authority calculated acute pesticide poisoning attack rate with the assumption that theentire population of children and employees was potentially exposed. The attack rate calculationincluded self-identified exposed non-employee adults and excluded other non-employee adults with theassumption that their potential for exposure was relatively limited.Oregon Health Authority classified thirty people (21% of those assumed to be exposed) as cases of acutepesticide poisoning. The NIOSH acute pesticide poisoning “certainty” index has eight classifications thatrange from “definite” to “unrelated” (APPENDIX D). This protocol classifies individuals with “definite”,“probable”, “possible”, or “suspicious” certainty indexes as acute pesticide poisoning cases. OregonHealth Authority assigned the following certainty classifications:6
Definite: two individuals (1% of total, “definite” cases have documented exposure and postexposure adverse health effects that are consistent with those described in the literature, andincluded supporting evidence from a medical evaluation or environmental sampling),Probable: one individual (1% of total, “probable” cases have either the exposure or the postexposure adverse health effects confirmed through a medical evaluation or environmentalsampling),Possible: 25 individuals (18% of total, in “possible” cases an individual reports an exposure andpost-exposure adverse health effects, though the reports are unconfirmed),Suspicious: two individuals (1% of total, in “suspicious” cases, there is insufficient evidence fromthe literature to support a causal relationship).Oregon Health Authority considered all acute pesticide poisoning cases as “low” severity, sincesymptoms (e.g., skin, eye or upper respiratory irritation) were mild, transient and resolvedspontaneously (NIOSH, 2017).Oregon Health Authority classified the remaining 19 respondents and all 93 non-respondents as notacute pesticide poisoning cases. Oregon Health Authority assigned the following certainty classificationsto the non-cases: Unlikely: eight individuals (6% of total, “unlikely” means that the described post-exposuresymptoms are not in line with those described in the literature),Insufficient information: eight individuals (6% of total, “insufficient information” applies ifinsufficient data are available on the exposure or post-exposure symptoms),Exposed but asymptomatic: two individuals (1% of total, “exposed but asymptomatic” applies ifthe person had no post-exposure findings),Not a case (since the individual did not attend Coos Bay Children’s Academy during the week ofMay 1): one individual (1% of total),Non-respondents: 93 individuals (66% of total).We assumed respondents declined to complete the questionnaire because they were not present duringthe exposure period or were asymptomatic. This final assumption may bias results towards lower acutepesticide poisoning attack rates if respondents were exposed and symptomatic but declined to completethe questionnaire for other reasons.Epidemic CurveEighteen acute pesticide poisoning cases (60%) reported experiencing their first symptom afterattending Coos Bay Children’s Academy on Monday, May 1 (Figure 1). Five (19%), three (11%) and one(4%) cases reported experiencing their first post-exposure symptom the following Tuesday throughThursday, respectively (Figure 1). Many cases, including those who reported their first symptom beforeattending Coos Bay Children’s Academy, also experienced additional symptoms after their first.7
Figure 1. Epidemic Curve for Acute Pesticide Poisoning Cases at Coos Bay Children’s Academy – FirstSymptom (Excludes first symptoms that were not new but worsened post-exposure, symptoms withunclear start dates and additional reported symptoms).Alternative CausesThirty-nine percent of all respondents had other medical conditions, such as allergies or asthma, whichmight explain their symptoms. This did not differ between cases and non-cases.DISCUSSIONAcute Pesticide Poisoning CasesOregon Health Authority classified 30 of the 49 respondents as low-severity acute pesticide poisoningcases. Most of these acute pesticide poisoning cases had a certainty index of “possible,” sinceindividuals reported attending Coos Bay Children’s Aca
Occupational Safety and Health’s (NIOSH) Sentinel Event Notification System for Occupational Risk . Tempo SC Ultra Premise Spray (EPA Reg. No. 11556-124) was the first pesticide used at Coos Bay Children’s Academy to treat for fleas. Coos Bay Children’s Academy applied the pesticides around the . Fast Cap Insecticide (EPA Reg. No .
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